Older adults’ willingness to consider deprescribing when experiencing hyperpolypharmacy

BackgroundOlder adults experiencing hyperpolypharmacy (use of 10 or more medications) are at an increased risk of cognitive impairment and functional decline. Deprescribing, where medications are stopped or tapered, is one strategy to mitigate risks.ObjectivesThe primary objective of our study was to use a card sorting activity to explore how older adults experiencing hyperpolypharmacy make hypothetical deprescribing decisions.MethodsWe recruited participants using our institutional research recruitment website between February and November 2020. Participant spoke with a research assistant to create a medication list and then completed an interview using card sorting activity to demonstrate how they would make hypothetical decisions about continuing or deprescribing their medications. Data from the card sorting activities and interviews were organized via Excel (Microsoft Corporation). We used the Pharmacy Quality Alliance Medication Therapy Problems Categories Framework to analyze participant’s reasons for considering deprescribing. The study was deemed exempt by the institutional review board.ResultsAmong the 26 participants, 14 (54%) identified as female, 19 (73%) were white, and 24 (92%) reported good or very good health. Participants reported a total of 405 medications (average 16, range 10-30). A total of 19 participants (73%) were interested in deprescribing 94 medications (23%), including stopping 68 medications (72%) and lowering the dose or frequency of 26 medications (28%). Common rationales for wanting to stop a medication included perceived lack of indication (n = 30, 32%), adherence (general preference to not take the medication) (n = 20, 21%), lack of effectiveness (n = 17, 18%), and concerns about safety (n = 14, 15%). We were unable to categorize 13 rationales (14%).ConclusionMost older adults experiencing hyperpolypharmacy were willing to consider deprescribing at least one medication. Future research is needed to identify whether a card sorting medication reflection activity can be used to provoke conversations about deprescribing between patients and primary care providers.     

Older adults’ understanding of hypothetical community pharmacy quality report cards

BackgroundQuality ratings for health plans and health services have become increasingly available to patients.ObjectiveWe sought to explore older adults’ understanding of hypothetical community pharmacy report cards and the information they valued on the report card.MethodsWe recruited participants aged 50 years or older to complete a 59-question telephone survey. The participants reviewed 3 different pairs of report cards, which represented a hypothetical pharmacy, and each pair contained different quality metrics. The participants identified which pharmacy of the pair they preferred, and this served as the primary outcome. We asked the participants to rate the level of importance (4-point unidirectional scale, not at all to very important) of the star ratings, source of information, and quality metrics. We also gathered information about the participants personal experiences with medications and pharmacy services, their self-reported health, health literacy, health numeracy, and demographics. The frequency that the pharmacy with higher quality metrics was selected was reported. We used logistic regression to examine factors associated with correctly identifying the highest quality pharmacy for all 3 sets of report cards.ResultsMost participants (n = 152) correctly identified all 3 (n = 120, 79.0%) report cards for pharmacies with higher quality metrics. The source of the information, individual quality metrics, and star ratings were all perceived as moderately or very important by most participants. Ratings of importance were strongly correlated (r, 0.70–1.00).ConclusionMore than 75% were able to correctly identify all 3 report cards with higher quality ratings. Most participants believed that the source of the information, the individual quality metrics, and the star rating were all important. Research is needed to explore to what extent patients would use these types of quality metric report cards to make decisions about where to obtain their medications.     

Benefits of deprescribing on patients’ adherence to medications

Deprescribing is a holistic process of medication cessation that encompasses gaining a comprehensive medication list, identifying potentially inappropriate medications, deciding if the identified medication can be ceased, planning the withdrawal regimen and monitoring, support and follow-up. It is currently being investigated as a mechanism to reduce unnecessary or redundant medications. However, given the systematic and patient-centred nature of the deprescribing process, it is possible that it may also confer additional benefits such as improving adherence to medications, even if there is no net reduction in overall medication use. Specifically, deprescribing may improve adherence via reducing polypharmacy, reducing the financial costs associated with medication taking, increasing the patient’s medication knowledge through education, increasing patient engagement in medication management and resolution of adverse drug reactions. More research into deprescribing must be conducted to establish if these potential benefits can be realised, in addition to establishing any negative consequences.     

Patients’ perceptions of a chronic pain rehabilitation program: changing the conversation

Objective Research supports the effectiveness of comprehensive approaches to chronic pain treatment, including behavioral management and physical reconditioning. However, less is known about patients’ perceptions of this treatment approach. The current study evaluated patient perceptions and treatment outcomes utilizing both qualitative and quantitative data collection.

Methods A total of 498 adult patients (≥18 years of age; M_age?=?49.1) completed an intensive outpatient interdisciplinary chronic pain rehabilitation program, completed survey measures at admission and discharge, and were asked open-ended questions about their treatment experience at discharge.

Results Patients reported significant decreases in pain severity, t(488)?=?23.08, p?<?.001, and pain-related interference, t(488)?=?24.28, p?<?.001, at discharge. Patients endorsed self-management strategies, particularly relaxation skills (85%), moderation and/or modification (47%), and exercise, stretching and/or physical therapy (39%) as the most important aspects of treatment.

Conclusions Patients perceive behavioral skills to manage pain and physical reconditioning to be important components of a successful pain rehabilitation program. These findings can inform conversations with both physicians and patients about the importance of biopsychosocial approaches to pain management. Key limitations include a lack of racial/ethnic diversity, use of anonymous data that cannot be linked directly to patient outcomes, and reliance on self-report data.     

Community pharmacists’ perceptions of leadership

BackgroundConcerns have been expressed regarding a “leadership crisis” in pharmacy. Previous research has identified potential barriers to pharmacists assuming leadership roles and signposted opportunities for further exploration of leadership issues in the profession related to psychological comfort with use of power.ObjectivesThis study explored community pharmacists’ perceptions of the effectiveness and impact of power leveraged by formal and informal pharmacy leaders.MethodsA theoretical framework based on Raven's 7 Sources of Power model was used to guide this research. Semi-structured interviews with community pharmacists in Ontario, Canada were undertaken, and data were coded and categorized using this framework.Findings29 pharmacists participated in this study. Participants in this study highlighted over-reliance on charismatic power, underuse of rewards and punishments, and general lack of effectiveness or impact in use of informational, expertise, positional, and relational powers amongst pharmacy leaders. Opportunities to broaden the power repertoire of pharmacy leaders, including leadership education, were identified as potentially valuable for individual leaders and the profession as a whole.ConclusionsEffectively leveraging power is important for leaders. This study has highlighted patterns of power use amongst community pharmacy leaders and identified opportunities for further research in this area and for continuing professional development for leaders.     

Nonprofessionals’ perceptions of the causes of behavioral and substance addictions

We assessed nonprofessionals' perceptions of etiological explanations of behavioral and substance addictions in a nationwide sample. A total of 612 adults (51% male) residing in the United States were recruited using Mechanical Turk. Participants rated the perceived likelihood of seven psychosocial and biological etiologies for one of five randomly assigned types of “addiction” (i.e., alcohol, marijuana, heroin, gambling, or pornography). Significantly fewer participants rated social pressure a likely cause of addiction to pornography (31%) than to marijuana (53%), alcohol (55%), and heroin (64%); significantly fewer rated traumatic childhood events a likely cause of addiction to gambling (33%) and marijuana (36%) than to pornography (56%), heroin (57%), and alcohol (64%); significantly fewer rated the way a person was raised a likely cause of addiction to marijuana (37%) than to heroin (55%) and alcohol (65%); and significantly more rated genetics a likely cause of an addiction to alcohol (65%) than to pornography (26%), marijuana (33%), gambling (41%), and heroin (45%). The proportions who rated stressful circumstances and character problem as likely causes were not significantly associated with type of addiction. In addition, participants rated an average of three or four separate etiologies as likely causes of each target addiction. Our results suggest that lay individuals recognize the multi-determined nature of addictive disorders and rate some causes as more or less likely depending on the specific addictive substance or behavior.     

Development and validation of the patients’ attitudes towards deprescribing (PATD) questionnaire

Background There is a large amount of research into and promotion of rational prescribing, but there is a comparative lack of investigation into deprescribing. The success of deprescribing is likely to be dependent on both medical and patient factors. Objective The aim of this study was to develop and validate a tool to capture the views and beliefs of patients regarding cessation of medications. Setting Participants were recruited from a multidisciplinary clinic at the Royal Adelaide Hospital and Hampstead Rehabilitation Centre. Methods The patients’ attitudes towards deprescribing (PATD) questionnaire was developed through expert opinion and piloting. Psychometric testing included face, content and criterion validity, sensitivity and test–retest reliability. Results A final 15 item questionnaire was produced. Through piloting, expert review and gamma rank correlation with the previously validated beliefs about medicines questionnaire, the PATD was determined to be valid. Test-retesting resulted in a total concordance of 71.3 % (95 % confidence interval, 64.1–78.5 %). Conclusion The PATD has acceptable psychometric properties and has potential for future use in research and practice to not only determine patients’ willingness towards deprescribing, but also uncover what beliefs may influence this.     

Australian drinkers’ perceptions of alcohol-related risk by consumption status

Background: This study investigated Australian drinkers’ alcohol-related beliefs according to their alcohol risk status. The primary aims were to assess drinkers’ awareness of the association between alcohol consumption and a range of health consequences and their understanding of the degree of risk represented by their own alcohol consumption.

Method: An online survey was administered to 2168 drinkers who consume alcohol at least twice per month. Respondents reported their alcohol intake levels and their beliefs relating to the relationship between alcohol and shorter-term (proximal) risks (e.g., drink-driving) and longer-term (distal) risks (e.g., stroke and cancer).

Results: Just over half (52%) of those drinking at high or very high risk levels did not perceive their drinking to be harmful. A large majority (85%) of the sample was aware of various short-term risks of excessive alcohol consumption, but only half appeared aware of the association between alcohol consumption and more distal health conditions.

Conclusions: The relatively low levels of awareness of the alcohol–disease link and the weak relationship between perceived risk and alcohol consumption levels suggest that attempts to reduce current high levels of alcohol-related harm could include public education campaigns designed to (i) improve drinkers’ understanding of the prevalence of alcohol-related harms upon which current alcohol guidelines are based, (ii) prompt drinkers to review their intake levels in the light of the guidelines to assess their potential risk of harm, and (iii) make alcohol-related risks more salient to every-day consumption decisions.     

Doctors’ and nurses’ perceptions of a ward-based pharmacist in rural northern Sweden

International Journal of Clinical Pharmacy - Background This project is part of the prospective quasi experimental proof-of-concept investigation of clinical pharmacist intervention study to reduce...     

Heroin uncertainties: Exploring users’ perceptions of fentanyl-adulterated and -substituted ‘heroin’

BackgroundThe US is experiencing an unprecedented opioid overdose epidemic fostered in recent years by regional contamination of the heroin supply with the fentanyl family of synthetic opioids. Since 2011 opioid-related overdose deaths in the East Coast state of Massachusetts have more than tripled, with 75% of the 1374 deaths with an available toxicology positive for fentanyl. Fentanyl is 30–50X more potent than heroin and its presence makes heroin use more unpredictable. A rapid ethnographic assessment was undertaken to understand the perceptions and experiences of people who inject drugs sold as ‘heroin’ and to observe the drugs and their use.MethodsA team of ethnographers conducted research in northeast Massachusetts and Nashua, New Hampshire in June 2016, performing (n = 38) qualitative interviews with persons who use heroin.Results(1) The composition and appearance of heroin changed in the last four years; (2) heroin is cheaper and more widely available than before; and (3) heroin ‘types’ have proliferated with several products being sold as ‘heroin’. These consisted of two types of heroin (alone), fentanyl (alone), and heroin–fentanyl combinations. In the absence of available toxicological information on retail-level heroin, our research noted a hierarchy of fentanyl discernment methods, with embodied effects considered most reliable in determining fentanyl’s presence, followed by taste, solution appearance and powder color. This paper presents a new ‘heroin’ typology based on users’ reports.ConclusionMassachusetts’ heroin has new appearances and is widely adulterated by fentanyl. Persons who use heroin are trying to discern the substances sold as heroin and their preferences for each form vary. The heroin typology presented is inexact but can be validated by correlating users’ discernment with drug toxicological testing. If validated, this typology would be a valuable harm reduction tool. Further research on adaptations to heroin adulteration could reduce risks of using heroin and synthetic opioid combinations.     

Community chain pharmacists’ perceptions of increased technicians’ involvement in the immunization process

BackgroundOver the past 2 decades, pharmacists have positioned immunization services as an important aspect of their expanding role in patient care.ObjectivesTo examine how community chain pharmacists view time spent on immunization, available in-store resources and barriers, and pharmacy technician involvement in the context of their views about the achievement of key National Vaccine Advisory Committee (NVAC) Standards of Adult Immunization Practice in their workplace.MethodsA representative, nationwide survey was administered electronically to chain community pharmacists over a 4-week period. Community pharmacists offering year-round immunization in retail chain, supermarket, and mass-merchant settings, randomly sampled from a database maintained by the American Pharmacists Association. We examined several sets of interrelated relationships regarding pharmacists’ perceived achievement of 3 key NVAC standards (assessment, recommendation and administration), time spent on the overall immunization process, the effectiveness of available in-store resources, immunization impediments, and the endorsement of increased technician involvement in community pharmacy-based immunization service (PBIS) delivery.ResultsA sample of 590 survey responses was obtained from 9717 e-mails delivered, with 489 deemed eligible (5% response rate). Sizeable numbers of pharmacists acknowledged that several activities integral to achieving optimal immunization levels were not being addressed. Although pharmacists accepted that appropriately trained pharmacy technicians should be able to ask (77%) and assess (66%) patients, only 24% agreed that technicians should be able to administer vaccine doses. Pharmacists satisfied with in-store immunization resources and technicians’ involvement were more likely to report achieving the 3 key NVAC standards. Paradoxically, how pharmacists viewed their immunization time expenditures was unrelated to whether they agreed that pharmacy technicians should have an expanded role in asking, assessing, or administering vaccines to their patients.ConclusionOverall, community pharmacies would likely better meet national immunization goals by achieving all 3 key NVAC standards and incorporating expanded roles for appropriately trained and supervised technicians in PBIS.